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pdfDisease Classification
OMB No: 0915-0310
Expiration Date: 10/31/2022
Public Burden Statement: The purpose of the data collection is to fulfill the legislative mandate
to establish and maintain a standardized database of allogeneic marrow and cord blood
transplants performed in the United States or using a donor from the United States. The data
collected also meets the C.W. Bill Young Cell Transplantation Program requirements to provide
relevant scientific information not containing individually identifiable information available to the
public in the form of summaries and data sets. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this information collection is 0915-0310 and it
is valid until 10/31/2022. This information collection is voluntary under The Stem Cell Therapeutic
and Research Act of 2005, Public Law (Pub. L.) 109–129, as amended by the Stem Cell
Therapeutic and Research Reauthorization Act of 2010, Public Law 111–264 (the Act) and the
Stem Cell Therapeutic and Research Reauthorization Act of 2015, Public Law 114-104. Public
reporting burden for this collection of information is estimated to average 0.43 hours per
response, including the time for reviewing instructions, searching existing data sources, and
completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville,
Maryland, 20857 or paperwork@hrsa.gov.
Registry Use Only
Sequence Number:
Date Received:
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Event date: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Primary Disease for HCT / Cellular Therapy
1. Date of diagnosis of primary disease for HCT / cellular therapy: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
2. What was the primary disease for which the HCT / cellular therapy was performed?
Acute myelogenous leukemia (AML or ANLL) (10) - Go to question 3
Acute lymphoblastic leukemia (ALL) (20) - Go to question 96
Acute leukemia of ambiguous lineage and other myeloid neoplasms (80) - Go to question 164
Chronic myelogenous leukemia (CML) (40) - Go to question 168
Myelodysplastic syndrome (MDS) (50) (If recipient has transformed to AML, indicate AML as the primary
disease.) - Go to question 179
Myeloproliferative neoplasms (MPN) (1460) (If recipient has transformed to AML, indicate AML as the primary
disease.) - Go to question 259
Other leukemia (30) (includes CLL) - Go to question 372
Hodgkin lymphoma (150) - Go to question 379
Non-Hodgkin lymphoma (100) - Go to question 379
Multiple myeloma / plasma cell disorder (PCD) (170) - Go to question 397
Solid tumors (200) - Go to question 444
CIBMTR Form 2402 revision 6 (1 – 89). Form released October 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Aplastic anemia (300) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.)
- Go to question 446
Inherited bone marrow failure syndromes (320) (If the recipient developed MDS or AML, indicate MDS or
AML as the primary disease.)– Go to question 449
Hemoglobinopathies (330) - Go to question 451
Paroxysmal nocturnal hemoglobinuria (PNH) (340) – Go to signature line
Disorders of the immune system (400) - Go to question 488
Inherited abnormalities of platelets (500) - Go to question 496
Inherited disorders of metabolism (520) - Go to question 498
Histiocytic disorders (570) - Go to question 501
Autoimmune diseases (600) - Go to question 506
Tolerance induction associated with solid organ transplant (910) - Go to question 510
Recessive dystrophic epidermolysis bullosa (920) – Go to First Name
Other disease (900) - Go to question 512
Acute Myelogenous Leukemia (AML)
Specify the AML classification
AML with recurrent genetic abnormalities
AML with t(9;11) (p22.3;q23.3); MLLT3-KMT2A (5)
AML with t(6;9) (p23;q34.1); DEK-NUP214 (6)
AML with inv(3) (q21.3;q26.2) or t(3;3) (q21.3;q26.2); GATA2, MECOM (7)
AML (megakaryoblastic) with t(1;22) (p13.3;q13.3); RBM15-MKL1 (8)
AML with t(8;21); (q22; q22.1); RUNX1-RUNX1T1 (281)
AML with inv(16) (p13.1;1q22) or t(16;16)(p13.1; q22); CBFB-MYH11 (282)
APL with PML-RARA (283)
AML with BCR-ABL1 (provisional entity) (3)
AML with mutated NPM1 (4)
AML with biallelic mutations of CEBPA (297)
AML with mutated RUNX1 (provisional entity) (298)
AML with 11q23 (MLL) abnormalities (i.e., t(4;11), t(6;11), t(9;11), t(11;19)) (284)
AML with myelodysplasia – related changes (285)
Therapy related AML (t-AML) (9)
AML, not otherwise specified
AML, not otherwise specified (280)
AML, minimally differentiated (286)
AML without maturation (287)
CIBMTR Form 2402 V6 (2 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
AML with maturation (288)
Acute myelomonocytic leukemia (289)
Acute monoblastic / acute monocytic leukemia (290)
Acute erythroid leukemia (erythroid / myeloid and pure erythroleukemia) (291)
Acute megakaryoblastic leukemia (292)
Acute basophilic leukemia (293)
Acute panmyelosis with myelofibrosis (294)
Myeloid sarcoma (295)
Myeloid leukemia associated with Down syndrome (299)
Did AML transform from MDS or MPN?
Yes – Also complete MDS or MPN Disease Classification questions
No
Is the disease (AML) therapy related?
Yes
No
Unknown
Did the recipient have a predisposing condition?
Yes - Go to question 7
No - Go to question 9
Unknown - Go to question 9
Specify condition
Bloom syndrome - Go to question 9
Down syndrome - Go to question 9
Fanconi anemia - Also complete CIBMTR Form 2029 – FAN - Go to question 9
Dyskeratosis congenita - Also complete CIBMTR Form 2028 – APL- Go to question 9
Other condition - Go to question 8
Specify other condition: __________________________________________
Labs at diagnosis
Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
Yes - Go to question 10
No - Go to question 23
Unknown - Go to question 23
CIBMTR Form 2402 V6 (3 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Were cytogenetics tested via FISH?
Yes – Go to question 11
No - Go to question 16
Results of tests
Abnormalities identified – Go to question 12
No abnormalities - Go to question 16
Specify cytogenetic abnormalities identified at diagnosis
International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
___________________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
CIBMTR Form 2402 V6 (4 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 15
Specify other abnormality: _____________________
Were cytogenetics tested via karyotyping?
Yes – Go to question 17
No - Go to question 22
Results of tests
Abnormalities identified – Go to question 18
No evaluable metaphases - Go to question 22
No abnormalities - Go to question 22
Specify cytogenetic abnormalities identified at diagnosis
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: _____________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
CIBMTR Form 2402 V6 (5 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 21
Specify other abnormality: _____________________
CIBMTR Form 2402 V6 (6 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
Yes
No
Were tests for molecular markers performed? (e.g. PCR, NGS) (at diagnosis)
Yes – Go to question 24
No – Go to question 36
Unknown – Go to question 36
Specify molecular markers identified at diagnosis
CEBPA
Positive – Go to question 25
Negative - Go to question 26
Not done - Go to question 26
Specify CEBPA mutation
Biallelic (homozygous)
Monoallelic (heterozygous)
Unknown
FLT3 – TKD (point mutations in D835 or deletions of codon I836)
Positive
Negative
Not done
FLT3 – ITD mutation
Positive- Go to question 28
Negative- Go to question 30
Not done- Go to question 30
FLT3 – ITD allelic ratio
Known - Go to question 29
Unknown - Go to question 30
Specify FLT3 - ITD allelic ratio: ___ . ___ ___
IDH1
Positive
Negative
CIBMTR Form 2402 V6 (7 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Not done
IDH2
Positive
Negative
Not done
KIT
Positive
Negative
Not done
NPM1
Positive
Negative
Not done
Other molecular marker
Positive- Go to question 35
Negative- Go to question 35
Not done- Go to question 36
Specify other molecular marker: _________________________________
Copy and complete questions 34-35 for multiple molecular markers
Labs between diagnosis and last evaluation
Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)
Yes - Go to question 37
No - Go to question 50
Unknown - Go to question 50
Were cytogenetics tested via FISH?
Yes – Go to question 38
No - Go to question 43
Results of tests
Abnormalities identified – Go to question 39
No abnormalities - Go to question 43
CIBMTR Form 2402 V6 (8 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify cytogenetic abnormalities identified between diagnosis and last evaluation
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: ____________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
CIBMTR Form 2402 V6 (9 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 42
Specify other abnormality: _____________________
Were cytogenetics tested via karyotyping?
Yes – Go to question 44
No - Go to question 49
Results of tests
Abnormalities identified – Go to question 45
No evaluable metaphases - Go to question 49
No abnormalities - Go to question 49
Specify cytogenetic abnormalities identified between diagnosis and last evaluation
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: ___________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
CIBMTR Form 2402 V6 (10 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 48
Specify other abnormality: _____________________
Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
Yes
No
Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis and last evaluation)
Yes – Go to question 51
No – Go to question 63
Unknown – Go to question 63
CIBMTR Form 2402 V6 (11 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify molecular markers identified between diagnosis and last evaluation
CEBPA
Positive – Go to question 52
Negative - Go to question 53
Not done - Go to question 53
Specify CEBPA mutation
Biallelic (homozygous)
Monoallelic (heterozygous)
Unknown
FLT3 – TKD (point mutations in D835 or deletions of codon I836)
Positive
Negative
Not done
FLT3 – ITD mutation
Positive- Go to question 55
Negative- Go to question 57
Not done- Go to question 57
FLT3 – ITD allelic ratio
Known - Go to question 56
Unknown - Go to question 57
Specify FLT3 - ITD allelic ratio: ___ . ___ ___
IDH1
Positive
Negative
Not done
IDH2
Positive
Negative
Not done
KIT
Positive
CIBMTR Form 2402 V6 (12 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
Negative
Not done
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
NPM1
Positive
Negative
Not done
Other molecular marker:
Positive- Go to question 62
Negative- Go to question 62
Not done- Go to question 63
Specify other molecular marker: _________________________________
Copy and complete questions 61-62 to report multiple other molecular markers
Labs at last evaluation
Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)
Yes - Go to question 64
No - Go to question 77
Unknown - Go to question 77
Were cytogenetics tested via FISH?
Yes – Go to question 65
No - Go to question 70
Results of tests
Abnormalities identified – Go to question 66
No abnormalities - Go to question 70
Specify cytogenetic abnormalities identified at last evaluation
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: ______________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
CIBMTR Form 2402 V6 (13 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Four or more (4 or more)
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 69
CIBMTR Form 2402 V6 (14 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify other abnormality: _____________________
Were cytogenetics tested via karyotyping?
Yes – Go to question 71
No - Go to question 76
Results of tests
Abnormalities identified – Go to question 72
No evaluable metaphases - Go to question 76
No abnormalities - Go to question 76
Specify cytogenetic abnormalities identified at last evaluation
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: _________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
-5
-7
-17
-18
-X
-Y
+4
+8
+11
+13
+14
+21
+22
t(3;3)
t(6;9)
t(8;21)
CIBMTR Form 2402 V6 (15 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(9;11)
t(9;22)
t(15;17) and variants
t(16;16)
del(3q) / 3q–
del(5q) / 5q–
del(7q) / 7q–
del(9q) / 9q–
del(11q) / 11q–
del(16q) / 16q–
del(17q) / 17q–
del(20q) / 20q–
del(21q) / 21q–
inv(3)
inv(16)
(11q23) any abnormality
12p any abnormality
Other abnormality - Go to question 75
Specify other abnormality: _____________________
Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
Yes
No
Were tests for molecular markers performed? (e.g. PCR, NGS) (at last evaluation)
Yes – Go to question 78
No – Go to question 90
Unknown – Go to question 90
Specify molecular markers identified at last evaluation
CEBPA
Positive – Go to question 79
Negative - Go to question 80
Not done - Go to question 80
Specify CEBPA mutation
Biallelic (homozygous)
CIBMTR Form 2402 V6 (16 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Monoallelic (heterozygous)
Unknown
FLT3– TKD (point mutations in D835 or deletions of codon I836)
Positive
Negative
Not done
FLT3 – ITD mutation
Positive- Go to question 82
Negative- Go to question 84
Not done- Go to question 84
FLT3 – ITD allelic ratio
Known - Go to question 83
Unknown - Go to question 84
Specify FLT3 - ITD allelic ratio: ___ . ___ ___
IDH1
Positive
Negative
Not done
IDH2
Positive
Negative
Not done
KIT
Positive
Negative
Not done
NPM1
Positive
Negative
Not done
Other molecular marker
CIBMTR Form 2402 V6 (17 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Positive- Go to question 89
Negative- Go to question 89
Not done- Go to question 90
Specify other molecular marker: _________________________________
Copy and complete questions 88-89 to report multiple other molecular markers
CNS Leukemia
Did the recipient have central nervous system leukemia at any time prior to the start of the preparative
regimen / infusion?
Yes
No
Unknown
Status at transplantation / infusion:
What was the disease status? (based on hematological test results)
Primary induction failure – Go to question 95
1st complete remission (no previous bone marrow or extramedullary relapse) (include CRi)– Go to
question 92
2nd complete remission (include CRi) – Go to question 92
≥ 3rd complete remission (include CRi) – Go to question 92
1st relapse – Go to question 94
2nd relapse – Go to question 94
≥ 3rd relapse – Go to question 94
No treatment – Go to question 95
How many cycles of induction therapy were required to achieve 1st complete remission? (includes
CRi)
1
2
≥3
Was the recipient in remission by flow cytometry?
Yes – Go to question 95
No – Go to question 95
Unknown – Go to question 95
CIBMTR Form 2402 V6 (18 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Not applicable – Go to question 95
Date of most recent relapse: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Acute Lymphoblastic Leukemia (ALL)
Specify ALL classification
B-lymphoblastic leukemia / lymphoma
B-lymphoblastic leukemia / lymphoma, NOS (B-cell ALL, NOS) (191)
B-lymphoblastic leukemia / lymphoma with t(9;22)(q34.1;q11.2); BCR-ABL1 (192)
B-lymphoblastic leukemia / lymphoma with t(v;11q23.3); KMT2A rearranged (193)
B-lymphoblastic leukemia / lymphoma with t(1;19)(q23;p13.3); TCF3-PBX1 (194)
B-lymphoblastic leukemia / lymphoma with t(12;21) (p13.2;q22.1); ETV6-RUNX1 (195)
B-lymphoblastic leukemia / lymphoma with t(5;14) (q31.1;q32.3); IL3-IGH (81)
B-lymphoblastic leukemia / lymphoma with Hyperdiploidy (51-65 chromosomes) (82)
B-lymphoblastic leukemia / lymphoma with Hypodiploidy (<46 chromosomes) (83)
B-lymphoblastic leukemia / lymphoma, BCR-ABL1-like (provisional entity) (94)
B-lymphoblastic leukemia / lymphoma, with iAMP21 (95)
T-cell lymphoblastic leukemia / lymphoma
T-cell lymphoblastic leukemia / lymphoma (Precursor T-cell ALL) (196)
Early T-cell precursor lymphoblastic leukemia (96)
NK cell lymphoblastic leukemia / lymphoma
Natural killer (NK)- cell lymphoblastic leukemia / lymphoma (97)
Did the recipient have a predisposing condition?
Yes - Go to question 98
No - Go to question 100
Unknown - Go to question 100
Specify condition
Aplastic anemia - Go to question 100 Also complete CIBMTR Form 2028 — APL
Bloom syndrome - Go to question 100
Down syndrome - Go to question 100
CIBMTR Form 2402 V6 (19 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Fanconi anemia - Go to question 100 Also complete CIBMTR Form 2029 — FAN
Other condition - Go to question 99
Specify other condition: _________________________________________
Were tyrosine kinase inhibitors given for therapy at any time prior to the start of the preparative regimen /
infusion? (e.g. imatinib mesylate, dasatinib, etc.)
Yes
No
Laboratory studies at diagnosis
Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
Yes - Go to question 102
No - Go to question 115
Unknown - Go to question 115
Were cytogenetics tested via FISH? (at diagnosis)
Yes - Go to question 103
No - Go to question 108
Results of tests (at diagnosis)
Abnormalities identified - Go to question 104
No abnormalities - Go to question 108
Specify cytogenetic abnormalities identified at diagnosis
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: ____________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
–7
+4
+8
+17
CIBMTR Form 2402 V6 (20 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
+21
t(1;19)
t(2;8)
t(4;11)
t(5;14)
t(8;14)
t(8;22)
t(9;22)
t(10;14)
t(11;14)
t(12;21)
del(6q) / 6q–
del(9p) / 9p–
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
12p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 46)
iAMP21
Other abnormality – Go to question 107
Specify other abnormality: _______________________________
Were cytogenetics tested via karyotyping? (at diagnosis)
Yes - Go to question 109
No - Go to question 114
Results of tests (at diagnosis)
Abnormalities identified - Go to question 110
No evaluable metaphases - Go to question 114
No abnormalities - Go to question 114
Specify cytogenetic abnormalities identified at diagnosis
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: ______________________________
CIBMTR Form 2402 V6 (21 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
–7
+4
+8
+17
+21
t(1;19)
t(2;8)
t(4;11)
t(5;14)
t(8;14)
t(8;22)
t(9;22)
t(10;14)
t(11;14)
t(12;21)
del(6q) / 6q–
del(9p) / 9p–
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
12p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 46)
iAMP21
Other abnormality – Go to question 113
Specify other abnormality: _________________________
Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
Yes
CIBMTR Form 2402 V6 (22 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No
Were tests for molecular markers performed? (e.g. PCR, NGS) (at diagnosis)
Yes – Go to question 116
No – Go to question 120
Unknown – Go to question 120
Specify molecular markers identified at diagnosis
BCR / ABL
Positive
Negative
Not done
TEL-AML / AML1
Positive
Negative
Not done
Other molecular marker
Positive – Go to question 119
Negative – Go to question 119
Not done – Go to question 120
Specify other molecular marker: ______________________________
Copy and complete questions 118-119 for additional molecular markers
Laboratory studies between diagnosis and last evaluation
Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)
Yes - Go to question 121
No - Go to question 134
Unknown - Go to question 134
Were cytogenetics tested via FISH? (between diagnosis and last evaluation)
Yes - Go to question 122
No - Go to question 127
Results of tests (between diagnosis and last evaluation)
CIBMTR Form 2402 V6 (23 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Abnormalities identified - Go to question 123
No abnormalities - Go to question 127
Specify cytogenetic abnormalities identified between diagnosis and last evaluation
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: _____________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
–7
+4
+8
+17
+21
t(1;19)
t(2;8)
t(4;11)
t(5;14)
t(8;14)
t(8;22)
t(9;22)
t(10;14)
t(11;14)
t(12;21)
del(6q) / 6q–
del(9p) / 9p–
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
12p any abnormality
Hyperdiploid (> 50)
CIBMTR Form 2402 V6 (24 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Hypodiploid (< 46)
iAMP21
Other abnormality – Go to question 126
Specify other abnormality: ___________________________
Were cytogenetics tested via karyotyping? (between diagnosis and last evaluation)
Yes - Go to question 128
No - Go to question 133
Results of tests (between diagnosis and last evaluation)
Abnormalities identified - Go to question 129
No evaluable metaphases - Go to question 133
No abnormalities - Go to question 133
Specify cytogenetic abnormalities identified between diagnosis and last
evaluation
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: _______________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
–7
+4
+8
+17
+21
t(1;19)
t(2;8)
t(4;11)
t(5;14)
t(8;14)
t(8;22)
t(9;22)
CIBMTR Form 2402 V6 (25 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(10;14)
t(11;14)
t(12;21)
del(6q) / 6q–
del(9p) / 9p–
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
12p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 46)
iAMP21
Other abnormality – Go to question 132
Specify other abnormality: _________________________
Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
Yes
No
Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis and last evaluation)
Yes – Go to question 135
No – Go to question 139
Unknown – Go to question 139
Specify molecular markers identified between diagnosis and last evaluation
BCR / ABL
Positive
Negative
Not done
TEL-AML / AML1
Positive
Negative
Not done
Other molecular marker
CIBMTR Form 2402 V6 (26 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Positive – Go to question 138
Negative – Go to question 138
Not done – Go to question 139
Specify other molecular marker: _________________________
Copy and complete questions 137-138 for additional molecular markers
Laboratory studies at last evaluation
Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)
Yes - Go to question 140
No - Go to question 153
Unknown - Go to question 153
Were cytogenetics tested via FISH?
Yes - Go to question 141
No - Go to question 146
Results of tests
Abnormalities identified - Go to question 142
No abnormalities - Go to question 146
Specify cytogenetic abnormalities identified at last evaluation
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: _________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
–7
+4
+8
+17
+21
CIBMTR Form 2402 V6 (27 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(1;19)
t(2;8)
t(4;11)
t(5;14)
t(8;14)
t(8;22)
t(9;22)
t(10;14)
t(11;14)
t(12;21)
del(6q) / 6q–
del(9p) / 9p–
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
12p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 46)
iAMP21
Other abnormality – Go to question 145
Specify other abnormality: ____________________
Were cytogenetics tested via karyotyping? (at last evaluation)
Yes - Go to question 147
No - Go to question 152
Results of tests
Abnormalities identified - Go to question 148
No evaluable metaphases - Go to question 152
No abnormalities - Go to question 152
Specify cytogenetic abnormalities identified at last evaluation
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string: _______________________________
Specify number of distinct cytogenetic abnormalities
CIBMTR Form 2402 V6 (28 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
–7
+4
+8
+17
+21
t(1;19)
t(2;8)
t(4;11)
t(5;14)
t(8;14)
t(8;22)
t(9;22)
t(10;14)
t(11;14)
t(12;21)
del(6q) / 6q–
del(9p) / 9p–
del(12p) / 12p–
add(14q)
(11q23) any abnormality
9p any abnormality
12p any abnormality
Hyperdiploid (> 50)
Hypodiploid (< 46)
iAMP21
Other abnormality – Go to question 151
Specify other abnormality: ____________________
Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)
Yes
No
CIBMTR Form 2402 V6 (29 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Were tests for molecular markers performed? (e.g. PCR, NGS) (at last evaluation)
Yes – Go to question 154
No – Go to question 158
Unknown – Go to question 158
Specify molecular markers identified at last evaluation
BCR / ABL
Positive
Negative
Not done
TEL-AML / AML1
Positive
Negative
Not done
Other molecular marker
Positive – Go to question 157
Negative – Go to question 157
Not done – Go to question 158
Specify other molecular marker: ___________________________
Copy and complete questions 156-157 for additional molecular markers
CNS Leukemia
Did the recipient have central nervous system leukemia at any time prior to the start of the preparative
regimen / infusion?
Yes
No
Unknown
Status at transplantation / infusion
What was the disease status? (based on hematological test results)
Primary induction failure – Go to question 163
1st complete remission (no previous marrow or extramedullary relapse) (include CRi) – Go to
question 160
2nd complete remission – Go to question 160
CIBMTR Form 2402 V6 (30 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
≥ 3rd complete remission – Go to question 160
1st relapse – Go to question 162
2nd relapse – Go to question 162
≥ 3rd relapse – Go to question 162
No treatment – Go to question 163
How many cycles of induction therapy were required to achieve 1st complete remission? (include
CRi)
1
2
≥3
Was the recipient in remission by flow cytometry?
Yes – Go to question 163
No – Go to question 163
Unknown – Go to question 163
Not applicable – Go to question 163
Date of most recent relapse: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms
Specify acute leukemias of ambiguous lineage and other myeloid neoplasm classification
Blastic plasmacytoid dendritic cell neoplasm (296) – Go to question 166
Acute undifferentiated leukemia (31) – Go to question 166
Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1 (84) – Go to question
166
Mixed phenotype acute leukemia with t(v; 11q23.3); KMT2A rearranged (85) – Go to question 166
Mixed phenotype acute leukemia, B/myeloid, NOS (86) – Go to question 166
Mixed phenotype acute leukemia, T/myeloid, NOS (87) – Go to question 166
Other acute leukemia of ambiguous lineage or myeloid neoplasm (88) - Go to question 165
Specify other acute leukemia of ambiguous lineage or myeloid neoplasm: __________________
Status at transplantation / infusion
CIBMTR Form 2402 V6 (31 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
What was the disease status? (based on hematological test results)
Primary induction failure
1st complete remission (no previous marrow or extramedullary relapse)
2nd complete remission
≥ 3rd complete remission
1st relapse
2nd relapse
≥3rd relapse
No treatment
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Chronic Myelogenous Leukemia (CML)
Was therapy given prior to this HCT?
Yes - Go to question 169
No - Go to question 175
Combination chemotherapy
Yes
No
Hydroxyurea (Droxia, Hydrea)
Yes
No
Tyrosine kinase inhibitor (e.g.imatinib mesylate, dasatinib, nilotinib)
Yes
No
Interferon-α (Intron, Roferon) (includes PEG)
Yes
No
Other therapy
Yes - Go to question 174
No - Go to question 175
Specify other therapy: ______________________________________
CIBMTR Form 2402 V6 (32 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
What was the disease status?
Complete hematologic response (CHR) preceded only by chronic phase- Go to question 176
Complete hematologic response (CHR) preceded by accelerated phase and/or blast phase- Go to
question 176
Chronic phase – Go to question 176
Accelerated phase - Go to question 177
Blast phase - Go to question 177
Specify level of response
No cytogenetic response (No CyR)
Minimal cytogenetic response
Minor cytogenetic response
Partial cytogenetic response (PCyR)
Complete cytogenetic response (CCyR)
Major molecular remission (MMR)
Complete molecular remission (CMR)
Number
1st
2nd
3rd or higher
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Myelodysplastic Syndrome (MDS)
What was the MDS subtype at diagnosis? – If transformed to AML, indicate AML as primary disease;
also complete AML Disease Classification questions
Atypical chronic myeloid leukemia (aCML), BCR-ABL1- (1440) – Go to question 376
Chronic myelomonocytic leukemia (CMMoL) (54) – Go to question 182
Juvenile myelomonocytic leukemia (JMML) (36) – Go to question 218
Myelodysplastic syndrome / myeloproliferative neoplasm, unclassifiable (69) – Go to question 181
MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN–RS–T) (1452) – Go to question
182
Myelodysplastic syndrome (MDS), unclassifiable (50)– Go to question 180
Myelodysplastic syndrome with isolated del(5q) (66)– Go to question 182
Myelodysplastic syndrome with multilineage dysplasia (MDS-MLD) (64) – Go to question 182
Myelodysplastic syndrome with single lineage dysplasia (MDS-SLD) (51) – Go to question 182
CIBMTR Form 2402 V6 (33 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Refractory cytopenia of childhood (68)– Go to question 182
Myelodysplastic syndrome with excess blasts (MDS-EB)
MDS with excess blasts-1 (MDS-EB-1) (61) – Go to question 182
MDS with excess blasts-2 (MDS-EB-2) (62) – Go to question 182
Myelodysplastic syndrome with ring sideroblasts (MDS-RS)
MDS-RS with single lineage dysplasia (MDS-RS-SLD) (1453) – Go to question 182
MDS-RS with multilineage dysplasia (MDS-RS-MLD) (1454) – Go to question 182
Specify Myelodysplastic syndrome, unclassifiable (MDS-U)
MDS-U with 1% blood blasts
MDS-U with single lineage dysplasia and pancytopenia
MDS-U based on defining cytogenetic abnormality
Was documentation submitted to the CIBMTR? (e.g. pathology report used for diagnosis)
Yes
No
Was the disease MDS therapy related?
Yes
No
Unknown
Did the recipient have a predisposing condition?
Yes – Go to question 184
No – Go to question 186
Unknown – Go to question 186
Specify condition
Aplastic anemia Also complete CIBMTR Form 2028 – APL – Go to question 186
DDX41-associated familial MDS – Go to question 186
Diamond-Blackfan Anemia – Go to question 186
Fanconi anemia –Go to question 186
GATA2 deficiency (including Emberger syndrome, MonoMac syndrome, DCML deficiency) –
Go to question 186
Li-Fraumeni Syndrome – Go to question 186
Paroxysmal nocturnal hemoglobinuria Also complete CIBMTR Form 2028 – APL – Go to
question 186
RUNX1 deficiency (previously “familial platelet disorder with propensity to myeloid
malignancies”) – Go to question 186
CIBMTR Form 2402 V6 (34 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
SAMD9- or SAMD9L-associated familial MDS – Go to question 186
Shwachman-Diamond Syndrome – Go to question 186
Telomere biology disorder (including dyskeratosis congenita) Also complete CIBMTR Form
2028 – APL – Go to question 186
Other condition – Go to question 185
Specify other condition: _______________________
Laboratory studies at diagnosis of MDS
Date CBC drawn: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
WBC
Known – Go to question 188
Unknown – Go to question 189
___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
x 106/L
Neutrophils
Known – Go to question 190
Unknown – Go to question 191
___ ___%
Blasts in blood
Known – Go to question 192
Unknown– Go to question 193
___ ___ ___ %
Hemoglobin
Known – Go to question 194
Unknown – Go to question 196
___ ___ ___ ___ ● ___ ___
g/dL
g/L
mmol/L
CIBMTR Form 2402 V6 (35 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Were RBCs transfused ≤ 30 days before date of test?
Yes
No
Platelets
Known – Go to question 197
Unknown – Go to question 199
___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
Were platelets transfused ≤ 7 days before date of test?
Yes
No
Blasts in bone marrow
Known – Go to question 200
Unknown – Go to question 201
___ ___ ___ %
Were cytogenetics tested (karyotyping or FISH)?
Yes – Go to question 202
No – Go to question 218
Unknown – Go to question 218
Were cytogenetics tested via FISH?
Yes- Go to question 203
No- Go to question 210
Sample source
Blood
Bone marrow
Results of tests
Abnormalities identified – Go to question 205
No abnormalities – Go to question 209
Specify cytogenetic abnormalities identified via FISH at diagnosis
CIBMTR Form 2402 V6 (36 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
__________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
Monosomy
–5
–7
–13
–20
–Y
Trisomy
+8
+19
Translocation
t(1;3)
t(2;11)
t(3;3)
t(3;21)
t(6;9)
t(11;16)
Deletion
del(3q) / 3q
del(5q) / 5q-
del(7q) / 7q-
del(9q) / 9q-
del(11q) / 11q-
del(12p) / 12p-
del(13q) / 13q-
CIBMTR Form 2402 V6 (37 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
del(20q) / 20q-
Inversion
inv(3)
Other
i17q
Other abnormality – Go to question 208
Specify other abnormality:__________________________
Was documentation submitted to the CIBMTR? (e.g. FISH report)
Yes
No
Were cytogenetics tested via karyotyping?
Yes- Go to question 211
No- Go to question 218
Sample source
Blood
Bone marrow
Results of tests
Abnormalities identified – Go to question 213
No evaluable metaphases- Go to question 217
No abnormalities – Go to question 217
Specify cytogenetic abnormalities identified via conventional cytogenetics at diagnosis
International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
__________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
CIBMTR Form 2402 V6 (38 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Monosomy
–5
–7
–13
–20
–Y
Trisomy
+8
+19
Translocation
t(1;3)
t(2;11)
t(3;3)
t(3;21)
t(6;9)
t(11;16)
Deletion
del(3q) / 3q
del(5q) / 5q-
del(7q) / 7q-
del(9q) / 9q-
del(11q) / 11q-
del(12p) / 12p-
del(13q) / 13q-
del(20q) / 20q-
Inversion
inv(3)
Other
i17q
Other abnormality – Go to question 216
Specify other abnormality:__________________________
Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
Yes
No
CIBMTR Form 2402 V6 (39 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Did the recipient progress or transform to a different MDS subtype or AML between diagnosis and the
start of the preparative regimen / infusion?
Yes – Go to question 219
No – Go to question 223
Specify the MDS subtype or AML after transformation
Chronic myelomonocytic leukemia (CMMoL) (54) – Go to question 221
Myelodysplastic syndrome / myeloproliferative neoplasm, unclassifiable (69) – Go to
question 221
MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN–RS–T) (1452) – Go to
question 221
Myelodysplastic syndrome (MDS), unclassifiable (50) – Go to question 220
Myelodysplastic syndrome with isolated del(5q) (66) – Go to question 221
Myelodysplastic syndrome with multilineage dysplasia (MDS-MLD) (64) – Go to question 221
Myelodysplastic syndrome with single lineage dysplasia (MDS-SLD)) (51) – Go to question
221
Refractory cytopenia of childhood (68) – Go to question 221
Transformed to AML (70) – Go to question 222
Myelodysplastic syndrome with excess blasts (MDS-EB)
MDS with excess blasts-1 (MDS-EB-1) (61) – Go to question 221
MDS with excess blasts-2 (MDS-EB-2) (62) – Go to question 221
Myelodysplastic syndrome with ring sideroblasts
MDS-RS with single lineage dysplasia (MDS-RS-SLD) (1453) – Go to question 221
MDS-RS with multilineage dysplasia (MDS-RS-MLD) (1454) – Go to question 221
Specify Myelodysplastic syndrome, unclassifiable (MDS-U)
MDS-U with 1% blood blasts– Go to question 221
MDS-U with single lineage dysplasia and pancytopenia– Go to question 221
MDS-U based on defining cytogenetic abnormality– Go to question 221
Specify the date of the most recent transformation:___ ___ ___ ___ — ___ ___ — ___ ___ Go to question 223
Date of MDS diagnosis: ___ ___ ___ ___ - ___ ___ - ___ ___ – Go to signature line
Laboratory studies at last evaluation prior to the start of the preparative regimen / infusion
Date CBC drawn: ___ ___ ___ ___ — ___ ___ — ___ ___
CIBMTR Form 2402 V6 (40 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
YYYY
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
MM
DD
WBC
Known – Go to question 225
Unknown – Go to question 226
___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
x 106/L
Neutrophils
Known – Go to question 227
Unknown – Go to question 228
___ ___%
Blasts in blood
Known – Go to question 229
Unknown – Go to question 230
___ ___ ___ %
Hemoglobin
Known – Go to question 231
Unknown – Go to question 233
___ ___ ___ ___ ● ___ ___
g/dL
g/L
mmol/L
Were RBCs transfused ≤ 30 days before date of test?
Yes
No
Platelets
Known – Go to question 234
Unknown – Go to question 236
___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
Were platelets transfused ≤ 7 days before date of test?
CIBMTR Form 2402 V6 (41 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
Yes
No
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Blasts in bone marrow
Known – Go to question 237
Unknown – Go to question 238
___ ___ ___ %
Were cytogenetics tested (karyotyping or FISH)?
Yes – Go to question 239
No – Go to question 255
Unknown – Go to question 255
Were cytogenetics tested via FISH?
Yes- Go to question 240
No- Go to question 247
Sample source
Blood
Bone marrow
Results of tests
Abnormalities identified – Go to question 242
No abnormalities – Go to question 246
Specify cytogenetic abnormalities identified via FISH at last evaluation prior to the
start of the preparative regimen / infusion
International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
__________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
Monosomy
CIBMTR Form 2402 V6 (42 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
–5
–7
–13
–20
–Y
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Trisomy
+8
+19
Translocation
t(1;3)
t(2;11)
t(3;3)
t(3;21)
t(6;9)
t(11;16)
Deletion
del(3q) / 3q
del(5q) / 5q-
del(7q) / 7q-
del(9q) / 9q-
del(11q) / 11q-
del(12p) / 12p-
del(13q) / 13q-
del(20q) / 20q-
Inversion
inv(3)
Other
i17q
Other abnormality – Go to question 245
Specify other abnormality:__________________________
Was documentation submitted to the CIBMTR? (e.g. FISH report)
Yes
No
CIBMTR Form 2402 V6 (43 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Were cytogenetics tested via karyotyping?
Yes- Go to question 248
No- Go to question 255
Sample source
Blood
Bone marrow
Results of tests
Abnormalities identified – Go to question 250
No evaluable metaphases- Go to question 254
No abnormalities – Go to question 254
Specify cytogenetic abnormalities identified via conventional cytogenetics at last
evaluation prior to the start of the preparative regimen / infusion
International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
__________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
Monosomy
–5
–7
–13
–20
–Y
Trisomy
+8
+19
Translocation
t(1;3)
t(2;11)
CIBMTR Form 2402 V6 (44 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
t(3;3)
t(3;21)
t(6;9)
t(11;16)
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Deletion
del(3q) / 3q
del(5q) / 5q-
del(7q) / 7q-
del(9q) / 9q-
del(11q) / 11q-
del(12p) / 12p-
del(13q) / 13q-
del(20q) / 20q-
Inversion
inv(3)
Other
i17q
Other abnormality – Go to question 253
Specify other abnormality:__________________________
Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
Yes
No
Status at transplantation / infusion
What was the disease status?
Complete remission (CR) –- Go to question 258
Hematologic improvement (HI) – Go to question 256
No response (NR) / stable disease (SD) – Go to question 258
Progression from hematologic improvement (Prog from HI) - Go to question 258
Relapse from complete remission (Rel from CR) - Go to question 258
Not assessed - Go to signature line
Specify the cell line examined to determine HI status (check all that apply)
HI-E –- Go to question 257
CIBMTR Form 2402 V6 (45 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
HI-P – Go to question 258
HI-N – Go to question 258
Specify transfusion dependence
Non transfused (NTD)-– Go to question 258
Low transfusion burden (LTB)- Go to question 258
Date assessed:
___ ___ ___ ___ — ___ ___ — ___ ___- Go to signature line
YYYY
MM
DD
Myeloproliferative Neoplasms (MPN)
What was the MPN subtype at diagnosis? – If transformed to AML, indicate AML as primary
disease; also complete AML Disease Classification questions
Chronic neutrophilic leukemia (165) –Go to Question 262
Chronic eosinophilic leukemia, not otherwise specified (NOS) (166) – Go to Question 262
Essential thrombocythemia (58) – Go to Question 262
Myeloproliferative neoplasm (MPN), unclassifiable (60) – Go to Question 261
Myeloid / lymphoid neoplasms with PDGFRA rearrangement (1461) – Go to Question 262
Myeloid / lymphoid neoplasms with PDGFRB rearrangement (1462) – Go to Question 262
Myeloid / lymphoid neoplasms with FGFR1 rearrangement (1463) – Go to Question 262
Myeloid / lymphoid neoplasms with PCM1-JAK2 (1464) – Go to Question 262
Polycythemia vera (PCV) (57) – Go to Question 262
Primary myelofibrosis (PMF) (167)- Go to Question 262
Mastocytosis
Cutaneous mastocytosis (CM) (1465) – Go to Question 262
Systemic mastocytosis (1470) - Go to Question 260
Mast cell sarcoma (MCS) (1466) – Go to Question 262
Specify systemic mastocytosis
Indolent systemic mastocytosis (ISM) – Go to Question 262
Smoldering systemic mastocytosis (SSM) – Go to question 262
Systemic mastocytosis with an associated hematological neoplasm (SM-AHN) – Go to
question 262
Aggressive systemic mastocytosis (ASM) – Go to question 262
Mast cell leukemia (MCL) – Go to question 262
Was documentation submitted to the CIBMTR? (e.g. pathology report used for diagnosis)
Yes
CIBMTR Form 2402 V6 (46 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No
Assessment at diagnosis
Did the recipient have constitutional symptoms in six months before diagnosis? (symptoms are >10%
weight loss in 6 months, night sweats, or unexplained fever higher than 37.5 °C)
Yes
No
Unknown
Laboratory studies at diagnosis of MPN
Date CBC drawn: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
WBC
Known – Go to question 265
Unknown – Go to question 266
___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
x 106/L
Neutrophils
Known – Go to question 267
Unknown – Go to question 268
___ ___%
Blasts in blood
Known – Go to question 269
Unknown– Go to question 270
___ ___ ___ %
Hemoglobin
Known – Go to question 271
Unknown – Go to question 273
___ ___ ___ ___ ● ___ ___
g/dL
g/L
CIBMTR Form 2402 V6 (47 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
mmol/L
Were RBCs transfused ≤ 30 days before date of test?
Yes
No
Platelets
Known – Go to question 274
Unknown – Go to question 276
___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
Were platelets transfused ≤ 7 days before date of test?
Yes
No
Blasts in bone marrow
Known – Go to question 277
Unknown – Go to question 278
___ ___ ___ %
Were tests for driver mutations performed?
Yes – Go to question 279
No – Go to question 289
Unknown - Go to question 289
JAK2
Positive– Go to question 280
Negative– Go to question 282
Not done– Go to question 282
JAK2 V617F
Positive
Negative
Not done
JAK2 Exon 12
Positive
CIBMTR Form 2402 V6 (48 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
Negative
Not done
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
CALR
Positive – Go to question 283
Negative– Go to question 286
Not done– Go to question 286
CALR type 1
Positive
Negative
Not done
CALR type 2
Positive
Negative
Not done
Not defined
Positive
Negative
Not done
MPL
Positive
Negative
Not done
CSF3R
Positive
Negative
Not done
Was documentation submitted to the CIBMTR?
Yes
No
Were cytogenetics tested (karyotyping or FISH)?
Yes – Go to question 290
CIBMTR Form 2402 V6 (49 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No – Go to question 306
Unknown – Go to question 306
Were cytogenetics tested via FISH?
Yes- Go to question 291
No- Go to question 298
Sample source
Blood
Bone marrow
Results of tests
Abnormalities identified – Go to question 293
No abnormalities – Go to question 297
Specify cytogenetic abnormalities identified via FISH at diagnosis
International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
__________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
Monosomy
–5
–7
–Y
Trisomy
+8
+9
Translocation
t(1;any)
t(3q21;any)
t(11q23;any)
CIBMTR Form 2402 V6 (50 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(12p11.2;any)
t(6;9)
Deletion
del(5q) / 5q
del(7q) / 7q-
del(11q) / 11q-
del(12p) / 12p-
del(13q) / 13q-
del(20q) / 20q-
Inversion
dup(1)
inv(3)
Other
i17q
Other abnormality – Go to question 296
Specify other abnormality:__________________________
Was documentation submitted to the CIBMTR? (e.g. FISH report)
Yes
No
Were cytogenetics tested via karyotyping?
Yes- Go to question 299
No- Go to question 306
Sample source
Blood
Bone marrow
Results of tests
Abnormalities identified – Go to question 301
No evaluable metaphases- Go to question 305
No abnormalities – Go to question 305
Specify cytogenetic abnormalities identified via conventional cytogenetics at diagnosis
CIBMTR Form 2402 V6 (51 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
__________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
Monosomy
–5
–7
–Y
Trisomy
+8
+9
Translocation
t(1;any)
t(3q21;any)
t(11q23;any)
t(12p11.2;any)
t(6;9)
Deletion
del(5q) / 5q
del(7q) / 7q-
del(11q) / 11q-
del(12p) / 12p-
del(13q) / 13q-
del(20q) / 20q-
Inversion
dup(1)
inv(3)
Other
i17q
Other abnormality – Go to question 304
CIBMTR Form 2402 V6 (52 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify other abnormality:__________________________
Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
Yes
No
Did the recipient progress or transform to a different MPN subtype or AML between diagnosis and the
start of the preparative regimen / infusion?
Yes – Go to question 307
No – Go to question 310
Specify the MPN subtype or AML after transformation
Post-essential thrombocythemic myelofibrosis (1467) – Go to question 308
Post-polycythemic myelofibrosis (1468) – Go to question 308
Transformed to AML (70) – Go to question 309
Specify the date of the most recent transformation:___ ___ ___ ___ — ___ ___ — ___ ___ Go to question 310
Date of MPN diagnosis: ___ ___ ___ ___ - ___ ___ - ___ ___ – Go to signature line
YYYY
MM
DD
Assessment at last evaluation prior to the start of the preparative regimen/ infusion
Specify transfusion dependence at last evaluation prior to the start of the preparative regimen/ infusion
Non-transfused (NTD) –(0 RBCs in 16 weeks)
Low-transfusion burden (LTB) -(3-7 RBCs in 16 weeks in at least 2 transfusion episodes;
maximum of 3 in 8 weeks)
High-transfusion burden (HTB) - (≥ 8 RBCs in 16weeks; ≥ 4 in 8 weeks)
Did the recipient have constitutional symptoms in six months before last evaluation prior to the start of
the preparative regimen / infusion? (symptoms are >10% weight loss in 6 months, night sweats, or
unexplained fever higher than 37.5 °C)
Yes
No
Unknown
Did the recipient have splenomegaly at last evaluation prior to the start of the preparative regimen/
infusion?
Yes – Go to question 313
CIBMTR Form 2402 V6 (53 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No – Go to question 316
Unknown- Go to question 316
Not applicable (splenectomy) – Go to question 316
Specify the method used to measure spleen size
Physical assessment- Go to question 314
Ultrasound- Go to question 315
CT/ MRI- Go to question 315
Specify the spleen size: ___ ___ centimeters below left costal margin – Go to question 317
Specify the spleen size:___ ___ centimeters
Did the recipient have hepatomegaly at last evaluation prior to the start of the preparative regimen /
infusion?
Yes – Go to question 317
No – Go to question 320
Unknown – Go to question 320
Specify the method used to measure liver size
Physical assessment- Go to question 318
Ultrasound- Go to question 319
CT/ MRI- Go to question 319
Specify the liver size: ___ ___ centimeters below right costal margin – Go to question 321
Specify the liver size: ___ ___ centimeters
Laboratory studies at last evaluation prior to the start of the preparative regimen / infusion
Date CBC drawn: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
WBC
Known – Go to question 322
Unknown – Go to question 323
___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3)
x 106/L
CIBMTR Form 2402 V6 (54 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Neutrophils
Known – Go to question 324
Unknown – Go to question 325
___ ___%
Blasts in blood
Known – Go to question 326
Unknown– Go to question 327
___ ___ ___ %
Hemoglobin
Known – Go to question 328
Unknown – Go to question 330
___ ___ ___ ___ ● ___ ___
g/dL
g/L
mmol/L
Were RBCs transfused ≤ 30 days before date of test?
Yes
No
Platelets
Known – Go to question 331
Unknown – Go to question 333
___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3)
x 106/L
Were platelets transfused ≤ 7 days before date of test?
Yes
No
Blasts in bone marrow
Known – Go to question 334
Unknown – Go to question 335
___ ___ ___ %
CIBMTR Form 2402 V6 (55 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Were tests for driver mutations performed?
Yes – Go to question 336
No – Go to question 346
Unknown - Go to question 346
JAK2
Positive– Go to question 337
Negative– Go to question 339
Not done– Go to question 339
JAK2 V617F
Positive
Negative
Not Done
JAK2 Exon 12
Positive
Negative
Not done
CALR
Positive – Go to question 340
Negative– Go to question 343
Not done– Go to question 343
CALR type 1
Positive
Negative
Not done
CALR type 2
Positive
Negative
Not done
Not defined
Positive
Negative
Not done
CIBMTR Form 2402 V6 (56 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
MPL
Positive
Negative
Not done
CSF3R
Positive
Negative
Not done
Was documentation submitted to the CIBMTR?
Yes
No
Were cytogenetics tested (karyotyping or FISH)?
Yes – Go to question 347
No – Go to question 363
Unknown – Go to question 363
Were cytogenetics tested via FISH?
Yes- Go to question 348
No- Go to question 355
Sample source
Blood
Bone marrow
Results of tests
Abnormalities identified – Go to question 350
No abnormalities – Go to question 354
Specify cytogenetic abnormalities identified via FISH at last evaluation prior to the
start of the preparative regimen / infusion
International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
__________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
CIBMTR Form 2402 V6 (57 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
Monosomy
–5
–7
–Y
Trisomy
+8
+9
Translocation
t(1;any)
t(3q21;any)
t(11q23;any)
t(12p11.2;any)
t(6;9)
Deletion
del(5q) / 5q
del(7q) / 7q-
del(11q) / 11q-
del(12p) / 12p-
del(13q) / 13q-
del(20q) / 20q-
Inversion
dup(1)
inv(3)
Other
i17q
Other abnormality – Go to question 353
Specify other abnormality:__________________________
Was documentation submitted to the CIBMTR? (e.g. FISH report)
Yes
No
CIBMTR Form 2402 V6 (58 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Were cytogenetics tested via karyotyping?
Yes- Go to question 356
No- Go to question 363
Sample source
Blood
Bone marrow
Results of tests
Abnormalities identified – Go to question 358
No evaluable metaphases- Go to question 362
No abnormalities – Go to question 362
Specify cytogenetic abnormalities identified via conventional cytogenetics at last
evaluation prior to the start of the preparative regimen / infusion
International System for Human Cytogenetic Nomenclature (ISCN) compatible string:
__________________________
Specify number of distinct cytogenetic abnormalities
One (1)
Two (2)
Three (3)
Four or more (4 or more)
Specify abnormalities (check all that apply)
Monosomy
–5
–7
–Y
Trisomy
+8
+9
Translocation
t(1;any)
t(3q21;any)
t(11q23;any)
t(12p11.2;any)
CIBMTR Form 2402 V6 (59 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
t(6;9)
Deletion
del(5q) / 5q
del(7q) / 7q-
del(11q) / 11q-
del(12p) / 12p-
del(13q) / 13q-
del(20q) / 20q-
Inversion
dup(1)
inv(3)
Other
i17q
Other abnormality – Go to question 361
Specify other abnormality:__________________________
Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
Yes
No
Status at transplantation / infusion
What was the disease status?
Complete clinical remission (CR) - Go to question 367
Partial clinical remission (PR) –- Go to question 367
Clinical improvement (CI) - Go to question 364
Stable disease (SD)- Go to question 367
Progressive disease - Go to question 367
Relapse- Go to question 367
Not assessed - Go to question 368
Was an anemia response achieved?
Yes
No
Was a spleen response achieved?
Yes
CIBMTR Form 2402 V6 (60 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No
Was a symptom response achieved?
Yes
No
Date assessed:
___ ___ ___ ___ — ___ ___ — ___ ___- Go to question 368
YYYY
MM
DD
Specify the cytogenetic response
Complete response (CR): Eradication of pre-existing abnormality – Go to question 369
Partial response (PR): ≥ 50% reduction in abnormal metaphases – Go to question 369
Re-emergence of pre-existing cytogenetic abnormality – Go to question 369
Not assessed – Go to question 370
Not applicable – Go to question 370
None of the above: Does not meet the CR or PR criteria – Go to question 369
Date assessed:
___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Specify the molecular response
Complete response (CR): Eradication of pre-existing abnormality – Go to question 371
Partial response (PR): ≥50% decrease in allele burden – Go to question 371
Re-emergence of a pre-existing molecular abnormality – Go to question 371
Not assessed – Go to First Name
Not applicable – Go to First Name
None of the above: Does not meet the CR or PR criteria – Go to 371
Date assessed:
___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Other Leukemia (OL)
Specify the other leukemia classification
Chronic lymphocytic leukemia (CLL), NOS (34) - Go to question 374
Chronic lymphocytic leukemia (CLL), B-cell / small lymphocytic lymphoma (SLL) (71) - Go to question
374
Hairy cell leukemia (35) - Go to question 377
Hairy cell leukemia variant (75) - Go to question 377
CIBMTR Form 2402 V6 (61 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Monoclonal B-cell lymphocytosis (76) – Go to signature line
Prolymphocytic leukemia (PLL), NOS (37) - Go to question 374
PLL, B-cell (73) - Go to question 374
PLL, T-cell (74) - Go to question 374
Other leukemia, NOS (30) - Go to question 377
Other leukemia (39) - Go to question 373
Specify other leukemia: _________________________________– Go to question 377
Was any 17p abnormality detected?
Yes – If disease classification is CLL, go to question 375. If PLL, go to question
377
No
Did a histologic transformation to diffuse large B-cell lymphoma (Richter syndrome) occur at any
time after CLL diagnosis?
Yes – Go to question 379
No – Go to question 377
Status at transplantation / infusion:
What was the disease status? (Atypical CML)
Primary induction failure – Go to question 378
1st complete remission (no previous bone marrow or extramedullary relapse) – Go to
question 378
2nd complete remission – Go to question 378
≥ 3rd complete remission – Go to question 378
1st relapse – Go to question 378
2nd relapse – Go to question 378
≥ 3rd relapse – Go to question 378
No treatment – Go to signature line
What was the disease status? (CLL, PLL, Hairy cell leukemia, Other leukemia)
Complete remission (CR) – Go to question 378
Partial remission (PR) – Go to question 378
Stable disease (SD) – Go to question 378
Progressive disease (Prog) – Go to question 378
Untreated - Go to question 378
Not assessed - Go to signature line
CIBMTR Form 2402 V6 (62 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Hodgkin and Non-Hodgkin Lymphoma
Specify the lymphoma histology (at infusion)
Hodgkin Lymphoma Codes
Hodgkin lymphoma, not otherwise specified (150)
Lymphocyte depleted (154)
Lymphocyte-rich (151)
Mixed cellularity (153)
Nodular lymphocyte predominant Hodgkin lymphoma (155)
Nodular sclerosis (152)
Non-Hodgkin Lymphoma Codes
B-cell Neoplasms
ALK+ large B-cell lymphoma (1833)
B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin
lymphoma (149)
Burkitt lymphoma (111)
Burkitt-like lymphoma with 11q aberration (1834)
Diffuse, large B-cell lymphoma- Activated B-cell type (non-GCB) (1821) - Go to question 381
Diffuse, large B-cell lymphoma- Germinal center B-cell type (1820) - Go to question 381
Diffuse large B-cell Lymphoma (cell of origin unknown) (107)
DLBCL associated with chronic inflammation (1825)
Duodenal-type follicular lymphoma (1815)
EBV+ DLBCL, NOS (1823)
EBV+ mucocutaneous ulcer (1824)
Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue type (MALT) (122)
Follicular, mixed, small cleaved and large cell (Grade II follicle center lymphoma) (103)
Follicular, predominantly large cell (Grade IIIA follicle center lymphoma) (162)
Follicular, predominantly large cell (Grade IIIB follicle center lymphoma) (163)
Follicular, predominantly large cell (Grade IIIA vs IIIB not specified) (1814)
Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma) (102)
Follicular (grade unknown) (164)
HHV8+ DLBCL, NOS (1826)
CIBMTR Form 2402 V6 (63 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements (1831)
High-grade B-cell lymphoma, NOS (1830)
Intravascular large B-cell lymphoma (136)
Large B-cell lymphoma with IRF4 rearrangement (1832)
Lymphomatoid granulomatosis (1835)
Mantle cell lymphoma (115)
Nodal marginal zone B-cell lymphoma (± monocytoid B-cells) (123)
Pediatric nodal marginal zone lymphoma (1813)
Pediatric-type follicular lymphoma (1816)
Plasmablastic lymphoma (1836)
Primary cutaneous DLBCL, leg type (1822)
Primary cutaneous follicle center lymphoma (1817)
Primary diffuse, large B-cell lymphoma of the CNS (118)
Primary effusion lymphoma (138)
Primary mediastinal (thymic) large B-cell lymphoma (125)
Splenic B-cell lymphoma/leukemia, unclassifiable (1811)
Splenic diffuse red pulp small B-cell lymphoma (1812)
Splenic marginal zone B-cell lymphoma (124)
T-cell / histiocytic rich large B-cell lymphoma (120)
Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173)
Other B-cell lymphoma (129) – Go to question 380
T-cell and NK-cell Neoplasms
Adult T-cell lymphoma / leukemia (HTLV1 associated) (134)
Aggressive NK-cell leukemia (27)
Anaplastic large-cell lymphoma (ALCL), ALK positive (143)
Anaplastic large-cell lymphoma (ALCL), ALK negative (144)
Angioimmunoblastic T-cell lymphoma (131)
Breast implant–associated anaplastic large-cell lymphoma (1861)
Chronic lymphoproliferative disorder of NK cells (1856)
Enteropathy-type T-cell lymphoma (133)
Extranodal NK / T-cell lymphoma, nasal type (137)
Follicular T-cell lymphoma (1859)
Hepatosplenic T-cell lymphoma (145)
Indolent T-cell lymphoproliferative disorder of the GI tract (1858)
Monomorphic epitheliotropic intestinal T-cell lymphoma (1857)
Mycosis fungoides (141)
CIBMTR Form 2402 V6 (64 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Nodal peripheral T-cell lymphoma with TFH phenotype (1860)
Peripheral T-cell lymphoma (PTCL), NOS (130)
Primary cutaneous acral CD8+ T-cell lymphoma (1853)
Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (1854)
Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (1852)
Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic largecell lymphoma (C-ALCL), lymphoid papulosis] (147)
Primary cutaneous γδ T-cell lymphoma (1851)
Sezary syndrome (142)
Subcutaneous panniculitis-like T-cell lymphoma (146)
Systemic EBV+ T-cell lymphoma of childhood (1855)
T-cell large granular lymphocytic leukemia (126)
Other T-cell / NK-cell lymphoma (139) – Go to question 380
Posttransplant lymphoproliferative disorders (PTLD)
Classical Hodgkin lymphoma PTLD (1876)
Florid follicular hyperplasia PTLD (1873)
Infectious mononucleosis PTLD (1872)
Monomorphic PTLD (B- and T-/NK-cell types) (1875)
Plasmacytic hyperplasia PTLD (1871)
Polymorphic PTLD (1874)
Specify other lymphoma histology: ______________________– Go to question 382
Assignment of DLBCL (germinal center B-cell type vs. activated B-cell type) subtype was based on:
Immunohistochemistry (e.g. Han’s algorithm)
Gene expression profile
Unknown method
Is the lymphoma histology reported at transplant a transformation from CLL?
Yes – Go to question 383
No - Go to question 384
Was any 17p abnormality detected?
Yes– Go to question 388
No– Go to question 388
Is the lymphoma histology reported at transplant a transformation from a different lymphoma histology? (Not
CLL)
Yes – Go to question 385
CIBMTR Form 2402 V6 (65 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No – Go to question 388
Specify the original lymphoma histology (prior to transformation) _________________
Specify other lymphoma histology:________________
Date of original lymphoma diagnosis:___ ___ ___ ___ - ___ ___ - ___ ___ (report the date of
diagnosis of original lymphoma subtype)
Was a PET (or PET/CT) scan performed? (at last evaluation prior to the start of the preparative regimen /
infusion)
Yes – Go to question 389
No – Go to question 394
Was the PET (or PET/CT) scan positive for lymphoma involvement at any disease site?
Yes
No
Date of PET scan
Known– Go to question 391
Unknown – Go to question 392
Date of PET (or PET/CT) scan: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
Deauville (five-point) score of the PET (or PET/CT) scan
Known – Go to question 393
Unknown – Go to question 394
Scale
1- no uptake or no residual uptake
2- slight uptake, but below blood pool (mediastinum)
3- uptake above mediastinal, but below or equal to uptake in the liver
4- uptake slightly to moderately higher than liver
5- markedly increased uptake or any new lesion
Status at transplantation / infusion:
What was the disease status?
Disease untreated– Go to signature line
CIBMTR Form 2402 V6 (66 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
DD
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
PIF res - Primary induction failure – resistant: NEVER in COMPLETE remission but with stable or
progressive disease on treatment. – Go to question 395
PIF sen / PR1 - Primary induction failure – sensitive: NEVER in COMPLETE remission but with partial
remission on treatment. – Go to question 395
PIF unk - Primary induction failure – sensitivity unknown– Go to question 395
CR1 - 1st complete remission: no bone marrow or extramedullary relapse prior to transplant– Go to
question 395
CR2 - 2nd complete remission– Go to question 395
CR3+ - 3rd or subsequent complete remission– Go to question 395
REL1 unt - 1st relapse – untreated; includes either bone marrow or extramedullary relapse– Go to
question 395
REL1 res - 1st relapse – resistant: stable or progressive disease with treatment– Go to question 395
REL1 sen - 1st relapse – sensitive: partial remission (if complete remission was achieved, classify as
CR2) – Go to question 395
REL1 unk - 1st relapse – sensitivity unknown– Go to question 395
REL2 unt - 2nd relapse – untreated: includes either bone marrow or extramedullary relapse– Go to
question 395
REL2 res - 2nd relapse – resistant: stable or progressive disease with treatment– Go to question 395
REL2 sen - 2nd relapse – sensitive: partial remission (if complete remission achieved, classify as
CR3+)– Go to question 395
REL2 unk - 2nd relapse – sensitivity unknown– Go to question 395
REL3+ unt - 3rd or subsequent relapse – untreated; includes either bone marrow or extramedullary
relapse– Go to question 395
REL3+ res - 3rd or subsequent relapse – resistant: stable or progressive disease with treatment– Go
to question 395
REL3+ sen - 3rd or subsequent relapse – sensitive: partial remission (if complete remission achieved,
classify as CR3+)– Go to question 395
REL3+ unk - 3rd relapse or greater – sensitivity unknown– Go to question 395
Total number of lines of therapy received (between diagnosis and HCT / infusion)
1 line
2 lines
3+ lines
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Multiple Myeloma / Plasma Cell Disorder (PCD)
Specify the multiple myeloma/plasma cell disorder (PCD) classification
Multiple myeloma (178) – Go to question 399
CIBMTR Form 2402 V6 (67 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Multiple myeloma-light chain only (186) - Go to question 399
Multiple myeloma-non-secretory (187) - Go to question 405
Plasma cell leukemia (172) - Go to question 407
Solitary plasmacytoma (no evidence of myeloma) (175) - Go to question 404
Smoldering myeloma (180) – Go to question 407
Amyloidosis (174) - Go to question 400
Osteosclerotic myeloma / POEMS syndrome (176) - Go to question 407
Monoclonal gammopathy of renal significance (MGRS) (1611) – Go to question 401
Other plasma cell disorder (179) - Go to question 398
Specify other plasma cell disorder: _________________________ - Go to question 407
Specify heavy and/or light chain type (check all that apply)
IgG kappa – Go to question 405
IgA kappa – Go to question 405
IgM kappa – Go to question 405
IgD kappa – Go to question 405
IgE kappa – Go to question 405
IgG lambda – Go to question 405
IgA lambda – Go to question 405
IgM lambda – Go to question 405
IgD lambda – Go to question 405
IgE lambda – Go to question 405
IgG (heavy chain only) – Go to question 405
IgA (heavy chain only) – Go to question 405
IgM (heavy chain only) – Go to question 405
IgD (heavy chain only) – Go to question 405
IgE (heavy chain only) – Go to question 405
Kappa (light chain only) – Go to question 405
Lambda (light chain only) – Go to question 405
Specify Amyloidosis classification
AL amyloidosis – Go to question 407
AH amyloidosis – Go to question 407
AHL amyloidosis – Go to question 407
Select monoclonal gammopathy of renal significance (MGRS) classification
Light chain fanconi syndrome – Go to question 403
CIBMTR Form 2402 V6 (68 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Proximal tubulopathy without crystals – Go to question 403
Crystal-storing histiocytosis – Go to question 403
Non-amyloid fibrillary glomerulonephritis – Go to question 403
Immunotactoid glomerulopathy (ITGN)/ Glomerulonephritis with organized monoclonal
microtubular immunoglobulin deposits (GOMMID) – Go to question 403
Type 1 cryoglobulinemic glomerulonephritis – Go to question 403
Monoclonal immunoglobulin deposition disease (MIDD) – Go to question 402
Proliferative glomerulonephritis with monoclonal immunoglobulin G deposits (PGNMID) – Go
to question 403
C3 glomerulopathy with monoclonal gammopathy – Go to question 403
Unknown – Go to question 403
Select monoclonal immunoglobulin deposition disease (MIDD) subtype
Light chain deposition disease (LCDD)
Light and heavy chain deposition disease (LHCDD)
Heavy chain deposition disease (HCDD)
Was documentation submitted to the CIBMTR? (e.g. pathology report)
Yes – Go to question 407
No – Go to question 407
Solitary plasmacytoma was
Extramedullary – Go to question 407
Bone derived – Go to question 407
What was the Durie-Salmon staging? (at diagnosis)
Stage I (All of the following: Hgb > 10g/dL; serum calcium normal or <10.5 mg/dL; bone x-ray normal
bone structure (scale 0), or solitary bone plasmacytoma only; low M-component production rates IgG
< 5g/dL, IgA < 3g/dL; urine light chain M-component on electrophoresis <4g/24h) – Go to question
406
Stage II (Fitting neither Stage I or Stage III) – Go to question 406
Stage III (One of more of the following: Hgb < 8.5 g/dL; serum calcium > 12 mg/dL; advanced lytic
bone lesions (scale 3); high M-component production rates IgG >7g/dL, IgA > 5g/dL; Bence Jones
protein >12g/24h) – Go to question 406
Unknown – Go to question 407
What was the Durie-Salmon sub classification? (at diagnosis)
A - relatively normal renal function (serum creatinine < 2.0 mg/dL)
B - abnormal renal function (serum creatinine ≥ 2.0 mg/dL)
Did the recipient have a preceding or concurrent plasma cell disorder?
CIBMTR Form 2402 V6 (69 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
Yes – Go to question 408
No – Go to question 411
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify preceding / concurrent disorder
Multiple myeloma– Go to question 410
Multiple myeloma-light chain only – Go to question 410
Multiple myeloma-non-secretory – Go to question 410
Plasma cell leukemia – Go to question 410
Solitary plasmacytoma (no evidence of myeloma) – Go to question 410
Smoldering myeloma – Go to question 410
Amyloidosis – Go to question 410
Osteosclerotic myeloma / POEMS syndrome – Go to question 410
Monoclonal gammopathy of unknown significance (MGUS) – Go to question 410
Monoclonal gammopathy of renal significance (MGRS) – Go to question 410
Other plasma cell disorder (PCD) – Go to question 409
Specify other preceding/concurrent disorder: ___________________________________
Date of diagnosis of preceding / concurrent disorder: ___ ___ ___ ___ — ___ ___ — ___
___
YYYY
Copy questions 408- 410 to report more than one concurrent or preceding disorder.
Serum β2-microglobulin
Known – Go to question 412
Unknown – Go to question 413
Serum β2-microglobulin: ___ ___ ___ ● ___ ___ ___
μg/dL
mg/L
nmol/L
Serum albumin
Known – Go to question 414
Unknown – Go to question 415
Serum albumin: ___ ___ ● ___ g/dL
g/L
I.S.S. at diagnosis
CIBMTR Form 2402 V6 (70 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
MM
DD
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Stage
Known – Go to question 416
Unknown – Go to question 417
Stage
1 (Serum β2-microglobulin < 3.5 mg/L, Serum albumin ≥ 3.5 g/dL)
2 (Not fitting stage 1 or 3)
3 (Serum β2-microglobulin ≥ 5.5 mg/L; Serum albumin —)
R - I.S.S. at diagnosis
Stage
Known – Go to question 418
Unknown – Go to question 419
Stage
1 (ISS stage I and no high-risk cytogenetic abnormalities by FISH [deletion 17p / 17p-, t(4;14),
t(14;16)] and normal LDH levels)
2 (Not R-ISS stage I or III)
3 (ISS stage III and either high-risk cytogenetic abnormalities by FISH [deletion 17p / 17p-,
t(4;14), t(14;16)] or high LDH levels)
Plasma cells in blood by flow cytometry
Known – Go to question 420
Unknown – Go to question 421
___ ___• ___ ___ %
Plasma cells in blood by morphologic assessment
Known – Go to question 422
Unknown – Go to question 424
___ ___%
___ ___ ___ ___ ___ • ___ ___ □ x 109/L (x 103/mm3)
□ x 106/L
LDH
Known – Go to question 425
Unknown – Go to question 427
CIBMTR Form 2402 V6 (71 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___ ___ ___ ___ ● ___ ___
U/L
μkat/L
Upper limit of normal for LDH: ___ ___ ___ ___ ___ • ___ ___
Labs at diagnosis
Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)
Yes – Go to question 428
No – Go to question 440
Unknown – Go to question 440
Were cytogenetics tested via FISH?
Yes – Go to question 429
No – Go to question 434
Results of tests
Abnormalities identified – Go to question 430
No abnormalities – Go to question 433
Specify cytogenetic abnormalities identified via FISH at diagnosis
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string:____________________
Specify abnormalities (check all that apply)
Trisomy
+3
+5
+7
+9
+11
+15
+19
Translocation
t(4;14)
t(6;14)
t(11;14)
CIBMTR Form 2402 V6 (72 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
t(14;16)
t(14;20)
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Deletion
del (13q) / 13q
del (17p) / 17p-
Monosomy
- 13
- 17
Other
Hyperdiploid (>50)
Hypodiploid (<46)
MYC rearrangement
Any abnormality at 1q
Any abnormality at 1p
Other abnormality– Go to question 432
Specify other abnormality:_______________________________
Was documentation submitted to the CIBMTR? (e.g. FISH report)
Yes
No
Were cytogenetics tested via karyotyping?
Yes – Go to question 435
No – Go to question 440
Results of tests
Abnormalities identified – Go to question 436
No evaluable metaphases – Go to question 439
No abnormalities – Go to question 439
Specify cytogenetic abnormalities identified via conventional cytogenetics at diagnosis
International System for Human Cytogenetic Nomenclature (ISCN) compatible
string:____________________
Specify abnormalities (check all that apply)
Trisomy
CIBMTR Form 2402 V6 (73 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
+3
+5
+7
+9
+11
+15
+19
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Translocation
t(4;14)
t(6;14)
t(11;14)
t(14;16)
t(14;20)
Deletion
del (13q) / 13q
del (17q) / 17p-
Monosomy
- 13
- 17
Other
Hyperdiploid (>50)
Hypodiploid (<46)
MYC rearrangement
Any abnormality at 1q
Any abnormality at 1p
Other abnormality– Go to question 438
Specify other abnormality:________________________________
Was documentation submitted to the CIBMTR? (e.g. karyotyping report)
Yes
No
Status at transplantation / infusion
What is the hematologic disease status?
Stringent complete response (sCR)
CIBMTR Form 2402 V6 (74 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Complete response (CR)
Very good partial response (VGPR )
Partial response (PR)
No response (NR) / stable disease (SD)
Progressive disease (PD)
Relapse from CR (Rel) (untreated)
Unknown
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line
YYYY
MM
DD
Specify amyloidosis hematologic response (for Amyloid patients only)
Complete response (CR)
Very good partial response (VGPR)
Partial response (PR)
No response (NR) / stable disease (SD)
Progressive disease (PD)
Relapse from CR (Rel) (untreated)
Unknown
Date assessed: ___ ___ ___ ___ - ___ ___ - ___ ___ – Go to signature line
YYYY
MM
DD
Solid Tumors
Specify the solid tumor classification
Bone sarcoma (excluding Ewing family tumors) (273)
Breast cancer (250)
Central nervous system tumor, including CNS PNET (220)
Cervical (212)
Colorectal (228)
Ewing family tumors of bone (including PNET) (275)
Ewing family tumors, extraosseous (including PNET) (276)
External genitalia (211)
Fibrosarcoma (244)
Gastric (229)
Germ cell tumor, extragonadal (225)
CIBMTR Form 2402 V6 (75 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Head / neck (201)
Hemangiosarcoma (246)
Hepatobiliary (207)
Leiomyosarcoma (242)
Liposarcoma (243)
Lung, non-small cell (203)
Lung, not otherwise specified (230)
Lung, small cell (202)
Lymphangio sarcoma (247)
Mediastinal neoplasm (204)
Medulloblastoma (226)
Melanoma (219)
Neuroblastoma (222)
Neurogenic sarcoma (248)
Ovarian (epithelial) (214)
Pancreatic (206)
Prostate (209)
Renal cell (208)
Retinoblastoma (223)
Rhabdomyosarcoma (232)
Soft tissue sarcoma (excluding Ewing family tumors) (274)
Synovial sarcoma (245)
Testicular (210)
Thymoma (231)
Uterine (213)
Vaginal (215)
Wilm tumor (221)
Solid tumor, not otherwise specified (200)
Other solid tumor (269) – Go to question 445
Specify other solid tumor: ________________________________- Go to signature line
Aplastic Anemia
Specify the aplastic anemia classification – If the recipient developed MDS or AML, indicate MDS or
AML as the primary disease.
Acquired AA, not otherwise specified (301) – Go to question 447
CIBMTR Form 2402 V6 (76 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Acquired AA secondary to chemotherapy (313) – Go to question 447
Acquired AA secondary to hepatitis (302) (any form of hepatitis)– Go to question 447
Acquired AA secondary to immunotherapy or immune effector cell therapy (314) – Go to question 447
Acquired AA secondary to toxin / other drug (303) – Go to question 447
Acquired amegakaryocytosis (not congenital) (304) – Go to Signature Line
Acquired pure red cell aplasia (not congenital) (306) – Go to Signature Line
Other acquired cytopenic syndrome (309) – Go to question 448
Specify severity
Severe / very severe – Go to Signature Line
Not severe – Go to Signature Line
Specify other acquired cytopenic syndrome: __________________________- Go to Signature
Line
Inherited Bone Marrow Failure Syndromes
Specify the inherited bone marrow failure syndrome classification - If the recipient developed MDS or
AML, indicate MDS or AML as the primary disease.
Diamond-Blackfan anemia (pure red cell aplasia) (312) – Go to question 450
Dyskeratosis congenita (307) – Go to signature line
Fanconi anemia (311)– Go to question 450
Severe congenital neutropenia (including Kostmann syndrome)(460) – Go to signature line
Shwachman-Diamond (305) – Go to question 450
Did the recipient receive gene therapy to treat the inherited bone marrow failure syndrome?
Yes - Also complete Cellular Therapy Product and Infusion forms 4003 and 4006.
No
Hemoglobinopathies
Specify the hemoglobinopathy classification
Sickle cell disease (356) – Go to question 454
Transfusion dependent thalassemia (360) – Go to question 452
Other hemoglobinopathy (359) – Go to question 453
Specify transfusion dependent thalassemia
Transfusion dependent beta thalassemia (357) – Go to question 454
Other transfusion dependent thalassemia (358) – Go to question 454
CIBMTR Form 2402 V6 (77 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify other hemoglobinopathy:______
Did the recipient receive gene therapy to treat the hemoglobinopathy?
Yes - Also complete Cellular Therapy Product and Infusion forms 4003 and 4006. If
transfusion dependent thalassemia, go to question 455, else go to signature line
No - If transfusion dependent thalassemia, go to question 455, else go to signature line
Questions 455-487 are for transfusion dependent thalassemia
Was tricuspid regurgitant jet velocity (TRJV) measured by echocardiography?
Yes – Go to question 456
No– Go to question 458
Unknown - Go to question 458
TRJV measurement
Known – Go to question 457
Unknown– Go to question 458
TRJV measurement: __ __● ___ m/sec
Was liver iron content (LIC) tested within 6 months prior to infusion?
Yes – Go to question 459
No – Go to question 461
Liver iron content: ___ ___ ___ ● ___
mg Fe/g liver dry weight
g Fe/kg liver dry weight
µmol Fe / g liver dry weight
Method used to estimate LIC?
T2*MRI
SQUID MRI
FerriScan
Liver biopsy
Other
Is the recipient red blood cell transfusion dependent? (requiring transfusion to maintain HGB 9-10
g/dL)
Yes – Go to question 462
No – Go to question 469
CIBMTR Form 2402 V6 (78 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Year of first transfusion (since diagnosis): ___ ___ ___ ___
YYYY
Was iron chelation therapy given at any time since diagnosis?
Yes – Go to question 464
No – Go to question 469
Unknown – Go to question 469
Did iron chelation therapy meet the following criteria: initiated within 18 months of the
first transfusion and administered for at least 5 days / week (either oral or parenteral
iron chelation medication)?
Yes, iron chelation therapy given as specified – 467
No, iron chelation therapy given, but not meeting criteria listed – Go to
question 465
Iron chelation therapy given, but details of administration unknown – Go to
question 467
Specify reason criteria not met
Non-adherence – Go to question 467
Toxicity due to iron chelation therapy – Go to question 467
Other – Go to question 466
Specify other reason criteria not met: ______________________
Year iron chelation therapy started
Known – Go to question 468
Unknown – Go to question 469
Year started: ___ ___ ___ ___
YYYY
Did the recipient have hepatomegaly? (≥ 2 cm below costal margin)
Yes– Go to question 470
No– Go to question 471
Unknown– Go to question 471
Liver size as measured below the costal margin at most recent evaluation: ___ ___ cm
Was a liver biopsy performed at any time since diagnosis?
Yes – Go to questions 472
No – Go to questions 479
CIBMTR Form 2402 V6 (79 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Date assessed
Known – Go to question 473
Unknown – Go to question 474
Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
□ Date estimated
DD
Was there evidence of liver cirrhosis?
Yes
No
Unknown
Was there evidence of liver fibrosis?
Yes – Go to question 476
No – Go to question 477
Unknown – Go to question 477
Type of fibrosis
Bridging
Periportal
Other
Unknown
Was there evidence of chronic hepatitis?
Yes
No
Unknown
Was documentation submitted to the CIBMTR? (e.g., liver biopsy)
Yes
No
Is there evidence of abnormal cardiac iron deposition based on MRI of the heart at time of infusion?
Yes
No
Did the recipient have a splenectomy?
Yes
No
CIBMTR Form 2402 V6 (80 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Unknown
Laboratory studies at last evaluation prior to start of preparative regimen
Serum iron
Known – Go to questions 482
Unknown – Go to questions 483
Serum iron: ___ ___ ___● ___ ___ µg / dL
µmol / L
Total iron binding capacity (TIBC)
Known – Go to question 484
Unknown – Go to question 485
TIBC: ___ ___ ___ ● ___ ___ µg / dL
µmol / L
Total serum bilirubin
Known – Go to question 486
Unknown – Go to question Signature line
Total serum bilirubin: ___ ___ ___ ● ___ mg/dL
μmol/L
Upper limit of normal for total serum bilirubin: ___ ___ ___ ● ___
Disorders of the Immune System
Specify disorder of immune system classification
Adenosine deaminase (ADA) deficiency / severe combined immunodeficiency (SCID) (401) – Go to
question 492
Absence of T and B cells SCID (402) – Go to question 492
Absence of T, normal B cell SCID (403) – Go to question 492
Omenn syndrome (404) – Go to question 492
Reticular dysgenesis (405) – Go to question 492
Bare lymphocyte syndrome (406) – Go to question 492
Other SCID (419) – Go to question 489
SCID, not otherwise specified (410) – Go to question 492
CIBMTR Form 2402 V6 (81 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Ataxia telangiectasia (451) – Go to question 492
HIV infection (452) – Go to question 492
DiGeorge anomaly (454) – Go to question 492
Common variable immunodeficiency (457) – Go to question 492
Leukocyte adhesion deficiencies, including GP180, CD-18, LFA and WBC adhesion deficiencies (459)
– Go to question 492
Neutrophil actin deficiency (461) – Go to question 492
Cartilage-hair hypoplasia (462) – Go to question 492
CD40 ligand deficiency (464) – Go to question 492
Other immunodeficiencies (479) – Go to question 490
Immune deficiency, not otherwise specified (400) – Go to question 492
Chediak-Higashi syndrome (456) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT
Data Form – Go to question 492
Griscelli syndrome type 2 (465) – Also complete Pigmentary Dilution Disorder (PDD) Pre-HCT Data
Form – Go to question 492
Hermansky-Pudlak syndrome type 2 (466) – Also complete Pigmentary Dilution Disorder (PDD)
Pre-HCT Data Form – Go to question 492
Other pigmentary dilution disorder (469) – Also complete Pigmentary Dilution Disorder (PDD) PreHCT Data Form – Go to question 491
Chronic granulomatous disease (455) – Go to question 492
Wiskott-Aldrich syndrome (453) – Go to question 492
X-linked lymphoproliferative syndrome (458) – Go to question 492
Specify other SCID: ____________________________ – Go to question 492
Specify other immunodeficiency: ____________________________– Go to question 492
Specify other pigmentary dilution disorder: ____________________________– Go to question
492
Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT?
Yes– Go to question 493
No– Go to question 494
Specify viral pathogen (check all that apply)
304 Adenovirus
341 BK Virus
344 Coronavirus
303 Cytomegalovirus (CMV)
347 Chikungunya Virus
CIBMTR Form 2402 V6 (82 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
346 Dengue Virus
325 Enterovirus (ECHO, Coxsackie)
327 Enterovirus D68 (EV-D68)
326 Enterovirus (polio)
328 Enterovirus NOS
318 Epstein-Barr Virus (EBV)
306 Hepatitis A Virus
307 Hepatitis B Virus
308 Hepatitis C Virus
340 Hepatitis E
301 Herpes Simplex Virus (HSV)
317 Human herpesvirus 6 (HHV-6)
309 Human Immunodeficiency Virus 1 or 2
343 Human metapneumovirus
322 Human Papillomavirus (HPV)
349 Human T-lymphotropic Virus 1 or 2
310 Influenza, NOS
323 Influenza A Virus
324 Influenza B Virus
342 JC Virus (Progressive Multifocal Leukoencephalopathy (PML))
311 Measles Virus (Rubeola)
312 Mumps Virus
345 Norovirus
316 Human Parainfluenza Virus (all species)
314 Respiratory Syncytial Virus (RSV)
321 Rhinovirus (all species)
320 Rotavirus (all species)
315 Rubella Virus
302 Varicella Virus
348 West Nile Virus (WNV)
Has the recipient ever been infected with PCP / PJP?
Yes
No
Does the recipient have GVHD due to maternal cell engraftment pre-HCT? (SCID only)
Yes
CIBMTR Form 2402 V6 (83 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No
Inherited Abnormalities of Platelets
Specify inherited abnormalities of platelets classification
Congenital amegakaryocytosis / congenital thrombocytopenia (501)
Glanzmann thrombasthenia (502)
Other inherited platelet abnormality (509) – Go to question 497
Specify other inherited platelet abnormality: ________________________________- Go to
signature line
Inherited Disorders of Metabolism
Specify inherited disorders of metabolism classification
Osteopetrosis (malignant infantile osteopetrosis) (521)
Leukodystrophies
Metachromatic leukodystrophy (MLD) (542)
Adrenoleukodystrophy (ALD) (543) – Go to question 500
Krabbe disease (globoid leukodystrophy) (544)
Lesch-Nyhan (HGPRT deficiency) (522)
Neuronal ceroid lipofuscinosis (Batten disease) (523)
Mucopolysaccharidoses
Hurler syndrome (IH) (531)
Scheie syndrome (IS) (532)
Hunter syndrome (II) (533)
Sanfilippo (III) (534)
Morquio (IV) (535)
Maroteaux-Lamy (VI) (536)
β-glucuronidase deficiency (VII) (537)
Mucopolysaccharidosis (V) (538)
Mucopolysaccharidosis, not otherwise specified (530)
Mucolipidoses
Gaucher disease (541)
Niemann-Pick disease (545)
I-cell disease (546)
CIBMTR Form 2402 V6 (84 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Wolman disease (547)
Glucose storage disease (548)
Mucolipidoses, not otherwise specified (540)
Polysaccharide hydrolase abnormalities
Aspartyl glucosaminidase (561)
Fucosidosis (562)
Mannosidosis (563)
Polysaccharide hydrolase abnormality, not otherwise specified (560)
Other inherited metabolic disorder (529) – Go to question 499
Inherited metabolic disorder, not otherwise specified (520)
Specify other inherited metabolic disorder: __________________________
signature line
- Go to
Loes composite score: __ __ Adrenoleukodystrophy (ALD) only - Go to signature line
Histiocytic Disorders
Specify histiocytic disorder classification
Hemophagocytic lymphohistiocytosis (HLH) (571) – Go to question 503
Langerhans cell histiocytosis (histiocytosis-X) (572)
Hemophagocytosis (reactive or viral associated) (573)
Malignant histiocytosis (574)
Other histiocytic disorder (579) – Go to question 502
Histiocytic disorder, not otherwise specified (570)
Specify other histiocytic disorder: ____________________________________- Go to signature
line
Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT?
Hemophagocytic lymphohistiocytosis (HLH) only
Yes– Go to question 504
No– Go to question 505
Specify viral pathogen (check all that apply)
304 Adenovirus
341 BK Virus
344 Coronavirus
CIBMTR Form 2402 V6 (85 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
303 Cytomegalovirus (CMV)
347 Chikaugunya Virus
346 Dengue Virus
325 Enterovirus (ECHO, Coxsackie)
327 Enterovirus D68 (EV-D68)
326 Enterovirus (polio)
328 Enterovirus NOS
318 Epstein-Barr Virus (EBV)
306 Hepatitis A Virus
307 Hepatitis B Virus
308 Hepatitis C Virus
340 Hepatitis E
301 Herpes Simplex Virus (HSV)
317 Human herpesvirus 6 (HHV-6)
309 Human Immunodeficiency Virus 1 or 2
343 Human metapneumovirus
322 Human Papillomavirus (HPV)
349 Human T-lymphotropic Virus 1 or 2
310 Influenza, NOS
323 Influenza A Virus
324 Influenza B Virus
342 JC Virus (Progressive Multifocal Leukoencephalopathy (PML))
311 Measles Virus (Rubeola)
312 Mumps Virus
345 Norovirus
316 Human Parainfluenza Virus (all species)
314 Respiratory Syncytial Virus (RSV)
321 Rhinovirus (all species)
320 Rotavirus (all species)
315 Rubella Virus
302 Varicella Virus
348 West Nile Virus (WNV)
Has the recipient ever been infected with PCP / PJP
Yes- Go to signature line
No- Go to signature line
CIBMTR Form 2402 V6 (86 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Autoimmune Diseases
Specify autoimmune disease classification
Arthritis
Rheumatoid arthritis (603)
Psoriatic arthritis / psoriasis (604)
Juvenile idiopathic arthritis (JIA): systemic (Stills disease) (640)
Juvenile idiopathic arthritis (JIA): oligoarticular (641)
Juvenile idiopathic arthritis (JIA): polyarticular (642)
Juvenile idiopathic arthritis (JIA): other (643)
Other arthritis (633)
Multiple sclerosis
Multiple sclerosis (602)
Connective tissue diseases
Systemic sclerosis (scleroderma) (607)
Systemic lupus erythematosis (SLE) (605)
Sjögren syndrome (608)
Polymyositis / dermatomyositis (606)
Antiphospholipid syndrome (614)
Other connective tissue disease (634)
Vasculitis
Wegener granulomatosis (610)
Classical polyarteritis nodosa (631)
Microscopic polyarteritis nodosa (632)
Churg-Strauss (635)
Giant cell arteritis (636)
Takayasu (637)
Behcet syndrome (638)
Overlap necrotizing arteritis (639)
Other vasculitis (611)
Other neurological autoimmune diseases
Myasthenia gravis (601)
Other autoimmune neurological disorder (644)
Hematological autoimmune diseases
Idiopathic thrombocytopenic purpura (ITP) (645)
Hemolytic anemia (646)
CIBMTR Form 2402 V6 (87 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Evan syndrome (647)
Other autoimmune cytopenia (648) – Go to question 507
Bowel diseases
Crohn’s disease (649)
Ulcerative colitis (650)
Other autoimmune bowel disorder (651) – Go to question 508
Metabolic
Diabetes mellitus type 1 (660)
Other
Other autoimmune disease (629) – Go to question 509
Specify other autoimmune cytopenia:_________________________________
Specify other autoimmune bowel disorder:_________________________________
Specify other autoimmune disease: ____________________
- Go to signature line
Tolerance Induction Associated with Solid Organ Transplant
Specify solid organ transplanted (check all that apply)
Kidney
Liver
Pancreas
Other organ - Go to question 511
Specify other organ: ______________________ - Go to signature line
Other Disease
Specify other disease: _________________________________________- Go to signature line
First Name: ____________________________________________________________________________
Last Name: _____________________________________________________________________________________
E-mail address: _________________________________________________________________________________
CIBMTR Form 2402 V6 (88 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Date: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
CIBMTR Form 2402 V6 (89 – 89) OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released October, 2020.
Copyright © 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
| File Type | application/pdf |
| Author | Monique Ammi |
| File Modified | 2020-10-22 |
| File Created | 2020-10-12 |